Abdominal Pain

Abdominal Pain

Description

• Parietal pain:
• Irritating material causing peritoneal inflammation
• Pain transmitted by somatic nerves
• Exacerbated by changes in tension of the peritoneum
• Pain characteristics:
• Sharp
• Well localized
• Abdominal tenderness
• Involuntary guarding
• Rebound tenderness
• Exacerbated by movement and coughing
• Visceral pain:
• Distention of a viscous or organ capsule or spasm of intestinal muscularis fibers:
• Pain is generally poorly localized.
• Colicky with intestinal distention
• Constant with a distended gallbladder or kidney
• Inflammation:
• Initially, the pain is poorly localized.
• Focal tenderness develops as the inflammation extends to the peritoneum or localizers.
• Ischemia from vascular disturbances:
• Pain is severe and diffuse with catastrophic vascular emergencies
• Pain is disproportional to the abdominal examination
• Referred pain:
• Felt at distant location from diseased organ
• Due to an overlapping supply by the affected neurosegment to the perceived location of pain
• Abdominal wall pain:
• Constant
• Aching
• Muscle spasm
• Involvement of other muscle groups

Etiology

• Peritoneal irritants:
• Gastric juice
• Fecal material
• Pus
• Blood
• Bile
• Pancreatic enzymes
• Visceral obstruction:
• Small intestines
• Large intestines
• Gallbladder
• Ureters and kidneys
• Visceral ischemia
• Intestinal
• Renal
• Splenic
• Visceral inflammation:
• Appendicitis
• Inflammatory bowel disorders
• Cholecystitis
• Hepatitis
• Peptic ulcer disease
• Pancreatitis
• Pelvic inflammatory disease
• Pyelonephritis
• Abdominal wall pain
• Referred pain:
• The possibility of intrathoracic disease must be considered in every patient with abdominal pain.

Diagnosis

Signs and Symptoms

• General:
• Anorexia
• Malaise
• Tachycardia
• Hypotension
• Fever
• Nausea
• Vomiting:
• Etiology requiring surgical intervention is less likely when vomiting precedes the onset of pain
• Abdominal:
• Diarrhea
• Constipation
• Distended abdomen
• Abnormal bowel sounds:
• High-pitched rushes with bowel obstruction
• Absence of sound with ileus or peritonitis
• Often unreliable
• Pulsatile abdominal mass
• Rovsing sign:
• Palpation of left lower quadrant causes pain in right lower quadrant (RLQ)
• Suggestive of appendicitis
• McBurney point tenderness associated with appendicitis:
• Palpation in RLQ two-thirds distance between umbilicus and right anterior superior iliac crest causes pain
• Murphy sign:
• Pause in inspiration while examiner is palpating under liver
• Suggestive of cholecystitis
• Psoas sign:
• Pain on extension of the thigh
• Suggests inflammation around psoas muscle
• Obturator sign
• Pain on rotation of the flexed thigh, especially internal rotation
• Inflammation around internal obturator muscle
• Tender or discolored hernia site
• Rectal and pelvic examination:
• Tenderness with pelvic peritoneal irritation
• Cervical motion tenderness
• Adnexal masses
• Rectal mass or tenderness
• Genitourinary:
• Flank pain
• Dysuria
• Hematuria
• Vaginal bleeding
• Tender adnexal mass on pelvis
• Testicular pain
• May be referred from renal or appendiceal pathology
• Testicular swelling
• High-riding testes
• Transverse lie of testis
• Extremities:
• Shoulder pain:
• Referred pain from diaphragmatic involvement
• Pulse deficit or unequal femoral pulses
• Skin:
• Jaundice
• Herpes zoster
• Cellulitis

Essential Workup

Historical characteristics define the type of pain and suggest underlying causes:

• Nature of onset of pain
• Time of onset and duration of pain
• Location of pain initially and at presentation
• Extra-abdominal radiations
• Quality of pain (e.g., sharp, dull, crampy)
• Palliative or provocative factors
• Relation of associated finding to onset of pain
• Changes in bowel habits
• History of trauma
• Gynecologic history
• Visceral obstruction

Tests

Lab

• CBC:
• WBC is a poor predictor of surgical disease
• Urinalysis
• Serum lipase:
• More accurate than a serum amylase in diagnosing pancreatic disorders
• hCG
• Serum electrolytes and glucose
• Liver function tests
• Gonorrhea and chlamydia cultures should be obtained if a pelvic examination is performed.

Imaging

• ECG:
• Indicated in patients with epigastric pain with risk factors for coronary artery disease
• Kidney, ureter, and bladder (KUB) and upright:
• Indicated primarily if bowel obstruction is suspected
• Air-fluid levels and intestinal distention:
• Bowel obstruction
• Ileus
• Volvulus
• Intussusception
• Upright chest radiograph:
• Pneumoperitoneum
• Perforated viscus
• Extra-abdominal causes
• Ultrasound:
• Biliary abnormalities
• Hydronephrosis
• Intraperitoneal fluid
• Aortic aneurysm
• Pelvic ultrasound

• Abdominal CT:
• Spiral CT without contrast:
• Determines location and size of stone in patients with renal colic
• CT with IV contrast only:
• Vascular rupture suspected in a stable patient
• CT with IV and oral contrast:
• Indicated when there is a suspicion of a surgical etiology involving bowel or intraperitoneal hemorrhage
• CT with rectal contrast only:
• High accuracy reported in detecting appendicitis
• IVP:
• Indicated in patients with suspected ureteral calculi
• More time-consuming than spiral CT
• Barium enema:
• Intussusception
• Volvulus

Differential Diagnosis

• Parietal pain:
• Abdominal arterial aneurysm
• Appendicitis
• Diverticulitis with perforation or abscess
• Ruptured ectopic pregnancy
• Ruptured ovarian cyst
• Pancreatitis
• Perforated peptic ulcer
• Perforated viscus
• Splenic rupture
• Visceral pain:
• Abdominal epilepsy
• Abdominal migraine
• Adrenal crisis
• Early Appendicitis
• Bowel obstruction
• Cholecystitis
• Constipation
• Depression
• Diabetic ketoacidosis
• Diverticulitis
• Dysmenorrhea
• Ectopic pregnancy
• Esophagitis
• Fecal impaction
• Fitz-Hugh–Curtis syndrome
• Gastroenteritis
• Hepatitis
• Hirschsprung disease
• Incarcerated hernia
• Inflammatory bowel disease
• Intussusception
• Irritable bowel syndrome
• Ischemic bowel
• Lactose intolerance
• Lead poisoning
• Meckel diverticulitis
• Neoplasm
• Ovarian torsion
• Pancreatitis
• Pelvic inflammatory disease
• Peptic ulcer disease
• Renal/ureteral calculi
• Sickle cell crisis
• Splenic infarction
• Spontaneous abortion
• Testicular torsion
• Urinary tract infection
• Volvulus
• Referred pain:
• Myocardial infarction
• Pneumonia
• Abdominal wall pain:
• Abdominal wall hematoma or infection
• Black widow spider bite
• Herpes zoster

Pediatric Considerations

• <2>
• Hirschsprung disease
• Incarcerated hernia
• Intussusception
• Neoplasm
• Sickle cell crisis
• Volvulus
• 2-5 years:
• Appendicitis
• Incarcerated hernia
• Meckel diverticulitis
• Neoplasm
• Sickle cell crisis
• >5 years:
• Appendicitis
• Ectopic pregnancy
• Inflammatory bowel disease
• Pelvic inflammatory disease

Treatment

Initial Stabilization

• Emergent laparotomy:
• Patients who are hemodynamically unstable with suspected vascular rupture
• IV fluids

ED Treatment

• Antiemetics are important for comfort.
• Narcotics or analgesics should not be withheld.
• Antibiotics are needed in potential perforation and in peritonitis.
• Surgical consultation based on suspected etiology

Medication (Drugs)

• Ampicillin: 0.5-2 g IV
• Cefotetan 1-2 g IV
• Cefoxitin: 1-2 g IV
• Compazine 5-10 mg PO prn nausea
• Gentamicin: 1-1.7 mg/kg IV
• Levofloxacin: 500 mg IV
• Metronidazole 15mg/kg IV, loading dose
• Ondansetron 4 mg IV prn nausea
• Promethazine: 12.5-25 mg PO/IM/IV

Follow-Up

Disposition

Admission Criteria

• Surgical intervention
• Peritoneal signs
• Patient unable to keep down fluids
• Lack of pain control
• Medical cause necessitating in-house treatment (myocardial infarction, diabetic ketoacidosis)
• IV antibiotics needed

Discharge Criteria

No surgical or severe medical etiology found in patient who is able to keep fluid down, has good pain control, and is able to follow detailed discharge instructions.

References
1. Graff LG 4th, Robinson D. Abdominal pain and emergency department evaluation. Emerg Med Clin North Am. 2001;19(1):123-136.
2. Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emerg Med Clin North Am. 2003;21(4):937-969.
3. Kamin RA, Nowicki TA, Courtney DS, Powers RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am. 2003;21(1):61-72
4. Kizer KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med. 1998;16(4):357-362.
5. Mason JD. The evaluation of acute abdominal pain in children. Emerg Med Clin North Am. 1996;14(3):629-643.

Codes
ICD9-CM
789.0
ICD10
R10.4